1st class lever - definition and example in the body
Force and resistance on opposite sides of the fulcrum (see-saw).
Triceps action at elbow.
2nd class lever - definition and example in the body
Force and resistance on same side of the fulcrum with resistance closer to the fulcrum (wheel barrow).
Push-ups and toe-raises. (Few examples in body).
3rd class lever - definition and example in the body
Force and resistance on same side of the fulcrum with force closer to the fulcrum.
Shoulder abduction, elbow extension. (Most common lever-type in the body).
Osteo/arthrokinematics: Interphalangeal joints
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Metacarpophalangeal joints
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Radiocarpal
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Distal radio-ulnar
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Proximal radio-ulnar
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Humeroradial
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Humeroulnar
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Glenohumeral
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Sternoclavicular
Shape of moving bone articular surface
Opposite/Same direction
Elevation/Depression: Convex, opposite
Protraction/Retraction: Concave, same
Osteo/arthrokinematics: Acromioclavicular
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Subtalar
Shape of moving bone articular surface
Opposite/Same direction
Anterior & middle calcaneus: Concave, same
Posterior calcaneus: Convex, opposite
Osteo/arthrokinematics: Talocrural
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Distal Tibiofibular
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Proximal Tibiofibular
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Knee
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Osteo/arthrokinematics: Hip
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: TMJ
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Atlanto-occipital
Shape of moving bone articular surface
Opposite/Same direction
Convex
Opposite
Osteo/arthrokinematics: Facet joints
Shape of moving bone articular surface
Opposite/Same direction
Concave
Same
Close/Loose-Packed position: Vertebral
Close: Maximal extension
Loose: Midway between flexion and extension
Close/Loose-Packed position: TMJ
Close: Maximal retrusion (teeth clenched) or maximal anterior position (mouth maximally opened)
Loose: Jaw slightly open
Close/Loose-Packed position: Sternoclavicular
Close: Maximal shoulder elevation
Loose: Arm resting at side
Close/Loose-Packed position: Acromioclavicular
Close: Shoulder abducted 90 degrees
Lose: Arm resting at side
Close/Loose-Packed position: Glenohumeral
Close: Maximal abduction and external rotation
Loose: 55-70 degrees abduction; 30 degrees horizontal adduction; neutral rotation
Close/Loose-Packed position: Humeroulnar
Close: Maximal extension and supination
Loose: 70 degrees flexion; 10 degrees supination
Close/Loose-Packed position: Humeroradial
Close: 90 degrees flexion; 5 degrees supination
Loose: Maximal extension and supination
Close/Loose-Packed position: Proximal/distal radioulnar
Proximal:
Close: 5 degrees supination; maximal extension
Loose: 70 degrees flexion; 35 degrees supination
Distal:
Close: 5 degrees supination
Loose: 10 degrees supination
Close/Loose-Packed position: Radiocarpal
Close: Maximal extension; radial deviation
Loose: Neutral; slight ulnar deviation
Close/Loose-Packed position: Midcarpal
Close: Maximal extension
Loose: Neutral; slight flexion; slight ulnar deviation
Close/Loose-Packed position: Carpometacarpal (2-5)
Close: Maximal opposition
Loose: Midway between flexion/extension
Close/Loose-Packed position: Trapeziometacarpal
Close: Maximal opposition
Loose: Midway between flexion/extension and adduction/abduction
Close/Loose-Packed position: Metacarpophalangeal 2-5
Close: Maximal flexion
Loose: Slight flexion; ulnar deviation
Close/Loose-Packed position: Proximal interphalangeal (hand)
Close: Maximal extension
Loose: 10 degrees flexion
Close/Loose-Packed position: Distal interphalangeal (hand)
Close: Maximal extension
Loose: 30 degrees flexion
Close/Loose-Packed position: Hip
Close: Ligamentous: Maximal extension; maximal abduction; maximal internal rotation
Bony: 90 degrees flexion; slight abduction; slight external rotation
Loose: 30 degrees flexion; 30 degrees abduction; slight external rotation
Close/Loose-Packed position: Knee
Close: Maximal extension; maximal external rotation of the tibia
Loose: 25 degrees flexion
Close/Loose-Packed position: Talocrural
Close: Maximal dorsiflexion
Loose: Midway between inversion/eversion; 10 degrees plantarflexion
Close/Loose-Packed position: Subtalar
Close: Maximal inversion
Loose: Midway between extremes of ROM; 10 degrees plantar flexion
Close/Loose-Packed position: Midtarsal
Close: Maximal supination
Loose: Midway between extremes of ROM; 10 degrees plantar flexion
Close/Loose-Packed position: Tarsometatarsal
Close: Maximal supination
Loose: Midway between supination/pronation
Close/Loose-Packed position: Metatarsophalangeal
Close: Maximal extension
Loose: Neutral (10 degrees extension)
Muscle substitution for weak pectoralis major
Long head of biceps; corocobrachialis; anterior deltoid
Muscle substitution for weak hip flexors
Lower abdominals; lower obliques; hip adductors; latissimus dorsi
Capsular pattern: Hip
Flexion and internal rotation, abduction, adduction and external rotation (add/ER limitation = little to none)
Capsular pattern: Subtalar
Increasing limitation of varus. When fixed in valgus: Inversion, eversion
Angles of head of humerus
20-30 degrees retroversion
Longitudinal axis of head is 135 degrees from axis of neck
Glenoid fossa position and shape
At lateral angle
Pear-shaped
Faces anteriorly, laterally and superiorly
Places true abduction at 30 degrees anterior to frontal plane
Corocohumeral ligament: Attachments and function
Base of coracoid to greater and lesser tubercles of the humerus.
Reinforces biceps tendon and superior capsule
Prevents caudal dislocation
(Taut with external rotation)
Scapulothoracic & Glenohumeral rhythm
At 75 degrees shoulder flexion, humerus external rotates to prevent compression of greaster tuberosity on acromion.
180 degrees abduction: 2:1 movement ratio
1st 30-60 degrees at GHJ
120 degrees of total movement occurs at GHJ
60 degrees of total movement occurs at scapulothoracic joint
Joint movements during shoulder flexion
Humerus glides inferiorly and external rotates
Clavical rotates at sternoclavicular joint
Scapula abducts and laterally rotates
Elbow 'Screw home' mechanism
Ulna pronates slightly with extension and supinates slightly with flexion
Proximal ulna glides medially during extension and laterally during flexion
Volar Plate
Thickening of capsule on palmar aspect of MCP, PIP and DIP joints.
More mobile at MCPs than IPs.
Finger ligs: Collateral
From lateral condyle to distal phalanx and lateral volar plate.
Tighten with flexion.
Volar fibers also tighten with extension.
1st CMC movement
Rotated position of trapezium places plane of flexion/extension of 1st CMC perpendicular to other digits.
Flexion/Abduction 1st CMC rotates ulnarly
Extension/Adduction 1st CMC rotates radially
Bursae Locations: Deep trochanteric
Between gluteaus maximus and posterior lateral greater trochanter (may cause pain on hip flexion and internal rotation due to compression of gluteus maximus)
Bursae Locations: Subacromial
Under deltoid, extending under acromion and coracoacromial arch above the joint capsule
Knee 'screw home' mechanism
At terminal extension the tibia externally rotates 5 degrees due to:
Lateral femoral condyle has a longer articular surface than medial (20 deg femoral roll laterally; 10-15 deg medially)
Medial meniscus attached to MCL which restricts medial gliding
Twisted cruciate ligaments
Lateral pull of quads
Talocrural osteokinematics
Open Chain Plantarflexion: Talus glides anteriorly on mortise and medially rotates slightly. (opposite for DF)
Closed Chain Plantarflexion: Tibia glides posteriorly on talus and laterally roates slightly. (opposite for DF)
Subtalar osteokinematics
Open Chain Inversion: Calcaneus adducts, supinates and plantarflexes on fixed talus. (opposite for eversion)
Closed Chain Inversion: Talus glides laterally, abducts and dorsiflexes. Produces external rotation of tibia. (opposite for eversion).
Talonavicular osteokinematics
Open Chain Inversion: Navicular plantarflexes, adducts and externally rotates on the talus. (opposite for eversion).
Closed Chain Inversion: Talus glides dorsally, abducts and internally rotates on navicular. (opposite for eversion)
Thoracic Spine "Rule of 3"
T1-T3 spinous processes even with transverse processes
T4-T6 spinous processes found 1/2 level below transverse processes
T7-T9 spinous processes at level of transverse process of vertebra below
T10 at level of vertebra below
T11 1/2 level below
T12 level with it's own transverse processes
Cervical Spine Coupled Movement Direction (rotation/side flexion)
Occiput/C1: Opposite
C2-C7: Same
Lumbar/Thoracic (in Neutral or extension): Opposite
Lumbar/Thoracic (in flexion): Same
(differs among individuals, should be tested prior to any manual technique)
Imaging uses: CT
(Enhanced X-rays)
Complex fractures, spinal stenosis, facet dyfunction, disc disease, poor quality imaging of soft tissues
Imaging uses: Discography
(Radiopaque dye injected into disc)
Specific technique to identify internal disc disruptions or the nucleus or annulus
Imaging uses: MRI
(uses magnetic field rather than radiation)
Two types:
T1: Visualizes fat within tissues - used for bones
T2: Surpresses fat - used for soft tissues
(CI: Claustrophobia, metal implants)
Imaging uses: Arthrography
(Inject water-soluble dye into joint)
Identify joint abnormalities eg - tendon rupture
Imaging uses: Bone Scan
(Radioactive chemicals injected, isotope settles in area of high metabolic activity)
Identify stress fractures, RA, bone cancer, bone infection
Imaging uses: Myelography
(Water-soluble dye injected into vertebral canal)
To assess discs and stenosis
(not used much as MRI/CT generally better and have less side-effects)
Neuro/Musculo screen (root origins of peripheral nerves): Upper and lower subscapular
C5-T1 (posterior cord)
Neuro/Musculo screen (root origins of peripheral nerves): Medial cutaneous (arm and forearm)
C8-T1 (medial cord)
Neuro/Musculo screen (root origins of peripheral nerves): Tibial
L4-S3 (becomes medial and lateral plantar nerves)
Neuro/Musculo screen (root origins of peripheral nerves): Common peroneal
L4-S2 (becomes deep and superficial peroneal nerves)
Neuro/Musculo screen (muscles supplied by peripheral nerves): Obturator
(adductors) Adductors longus, brevis, magnus; gracilis, obturator externus
Neuro/Musculo screen (muscles supplied by peripheral nerves): Accessory obturator
(Usually absent) Pectineus
Neuro/Musculo screen (muscles supplied by peripheral nerves): Tibial
(posterior leg and thigh) Temitendinosus, semitmembranosus, long head of biceps femoris, adductor magnus, gactocnemius, soleus, plantaris, popliteus, FDL, FHL, tibialis posterior
Neuro/Musculo screen (muscles supplied by peripheral nerves): Medial plantar
(from tibial nerve - supplies medial sole of the foot) FHB, AbH, FDB, 1st lumbricle
Neuro/Musculo screen (muscles supplied by peripheral nerves): Lateral plantar
(from tibial nerve - supplies lateral sole of foot) Quadratus plantae, lateral 4 lumbricles, AdH, FDM, AbDM, interossei
Neuro/Musculo screen (muscles supplied by peripheral nerves): Femoral
(anterior thigh) Iliacus, pectineus, sartorius, quadriceps
Neuro/Musculo screen (muscles supplied by peripheral nerves): Superor gluteal
Gluteus medius and minimus, TFL
Neuro/Musculo screen (muscles supplied by peripheral nerves): Common peroneal
Biceps femoris (short head)
Neuro/Musculo screen (muscles supplied by peripheral nerves): Deep peroneal
(anterior leg) Tibialis anterior, EDL, peroneus tertius, EHL, EDB
Neuro/Musculo screen (muscles supplied by peripheral nerves): Superficial peroneal
(lateral leg) Peroneus longus and brevis
Neuro/Musculo screen (muscles supplied by peripheral nerves): Dorsal scapular
Rhomboids, levator scapulae
Neuro/Musculo screen (muscles supplied by peripheral nerves): Suprascapular
Supraspinatus, infraspinatus
Neuro/Musculo screen (muscles supplied by peripheral nerves): Lateral pectoral
Pertoralis major and minor
Neuro/Musculo screen (muscles supplied by peripheral nerves): Musculocutaneous
Biceps brachii, corocobrachialis, brachialis
Neuro/Musculo screen (muscles supplied by peripheral nerves): Lower subscapular
Subscapularis, teres major
Neuro/Musculo screen (muscles supplied by peripheral nerves): Radial
(posterior arm and forearm) Triceps, anconeus, brachioradialis, ECRL, ECRB, supinator, ED, EDM, EI, AbPL
Neuro/Musculo screen (muscles supplied by peripheral nerves): Median
(anterior forearm - radial side) Pronator teres, pronator quadratus, FCR, radial 1/2 FDP, FDS, FPL, thenar eminence (FPB (superficial head), AbP, OpP), lateral 2 lumbricles
Neuro/Musculo screen (muscles supplied by peripheral nerves): Medial pectoral
Pectoralis major and minor
Neuro/Musculo screen (muscles supplied by peripheral nerves): Ulnar
(hand and anterior forearm - ulnar side) FCU, ulnar 1/2 of FDP, hypothenar eminence (AbDM, OpDM, FDM) interossei, medial 2 lumbricles, AdP, deep head of FPB
Trunk/Ribcage musculo/neuro testing (muscles, cord segment, nerves): Inspiration
Diaphragm (C3-C5) Phrenic nerve
Levator costarum, external intercostals, anterior internal intercostals (T1-T12) Intercostal nerve
Trunk/Ribcage musculo/neuro testing (muscles, cord segment, nerves): Forced expiration
Internal obliques, transverse abdominis (T7-L1) Intercostal nerve
External obliques, posterior internal intercostals, rectus abdominis (T7-T12) Intercostal nerve
Trunk/Ribcage musculo/neuro testing (muscles, cord segment, nerves): Spine extension
Erector spinae, transversospinalis, interspinales, rotatores, intertransversarii (T1-T12, L1-L5, S1-S3)
Trunk/Ribcage musculo/neuro testing (muscles, cord segment, nerves): Spine flexion
Rectus abdominis/external obliques (T7-T12) Intercostal nerve
Internal obliques (T7-L1) Intercostal nerve
Psoas Minor (L1) Lumbar plexus
Trunk/Ribcage musculo/neuro testing (muscles, cord segment, nerves): Spine rotation
Rotatores, internal/external obliques, intertransversarii, transversospinalis (T1-T12, L1-L5, S1-S3)
Trunk/Ribcage musculo/neuro testing (muscles, cord segment, nerves): Spine lateral flexion
Quadratus lumborum (T12-L3) Lumbar plexus
ROM norms: Shoulder
Flexion/Extension: 160-180/50-60
Abd/Add: 170-180/50-75
ER/IR: 80-90/60-100
Horizontal add: 130-145
Special Tests (structure being tested & procedure): Yergason's Test
Transverse ligament and bicipital tendonitis
pronation and 90 deg elbow flexion
resist supination and external rotation
Special Tests (structure being tested & procedure): Speed's
Bicipital tendonitis/osis
90 deg shoulder flexion, full elbow extension, supination
Resist shoulder flexion
Special Tests (structure being tested & procedure): Neer impingement
Long head of biceps and supraspinatus impingement
Passive internal rotation followed by full passive abduction
Special Tests (structure being tested & procedure): Empty can
Tear/impingement of supraspinatus or suprascapular nerve pathology
Shoulder at 90 deg abduction, no rotation, resist abduction
Horizontally adducted shoulder 30 deg, full IR, resist abduction
Special Tests (structure being tested & procedure): Drop arm test
Tear/rupture of rotator cuff
Passive shoulder abduction 120 deg
Patient slowly lowers arm to side (guard incase arm gives way)
+ve if patient unable to slowly to lower to side
Special Tests (structure being tested & procedure): Posterior internal impingement
Impingment of rotator cuff on greater tuberosity or posterior labrum
Supine, passive 90 deg abd, max ER, 15-20 deg horizonal add
Special Tests (structure being tested & procedure): Clunk test
Glenoid labrum tear
Supine, full abduction
PA humeral head with ER
Special Tests (structure being tested & procedure): Posterior apprehension sign
Supine, shoulder abducted 90 deg in scapular plane
AP through elbow with IR and horizontal add
Special Tests (structure being tested & procedure): AC shear test
SC joint dysfunction (arthritis, seperation etc)
Sitting, arm at side
PT clasps hands with heel of one hand on spine of scapula, other on clavicle
Squeeze hands to compress AC
Special Tests (structure being tested & procedure): Adson's
Thoracic outlet syndrome
Sitting, find radial pulse
Neck rotation towards test side
Shoulder extension and ER with neck extension
(looking for neurological/vascular signs)
Special Tests (structure being tested & procedure): Costoclavicular syndrome (Military brace) test
Thoracic outlet syndrome
Sitting, find radial pulse
Move test shoulder back and down
(Looking for neurological/vascular signs)
Special Tests (structure being tested & procedure): Wright (hyperabduction) test
Thoracic outlet syndrome
Sitting, find radial pulse
Passive shoulder abduction and ER
Deep breath with contralateral neck rotation may increase symptoms
(Looking for neurological/vascular signs)
Special Tests (structure being tested & procedure): Roos elevated arm test
Thoracic outlet
Standing, shoulders abducted 90 deg, full ER, slight horizontal abduction, 90 deg elbow flexion
Patient opens and closes hands slowly for 3 minutes
(Looking for neurological/vascular signs)
Special Tests (structure being tested & procedure): Elbow ligament instability
Varus/valgus forces with elbow in 20-30 deg flexion
Special Tests (structure being tested & procedure): Lateral epicondylitis
90 degrees elbow flexion
Resist wrist extension, pronation and radial deviation with hand in fist
Cozen's test - as above with elbow in slight flexion and palpation of lateral epicondyle
Special Tests (structure being tested & procedure): Medial epicondylitis
90 degrees elbow flexion
Passive supination, elbow and wrist extension
Special Tests (structure being tested & procedure): Pronator teres syndrome test
Median nerve entrapment within pronator teres
Sitting, elbow flexed to 90 degrees
Resist pronation and elbow extension
(looking for tingling/paresthesia in median nerve distribution)
Special Tests (structure being tested & procedure): Finkelstein
deQuervain's tensynovitis (AbPL, EPB)
Fist with thumb inside
Passive ulnar deviation
Special Tests (structure being tested & procedure): Bunnel-Littler
Tightness in structures around MCP joints
MCP held in slight extension, PIP flexed
MCP and PIP flexed
If flexion limited in both tests, capsule is tight
If flexing MCP increases PIP ROM, intrinsic muscles are tight
Special Tests (structure being tested & procedure): Tight retinacular test
Tightness around PIP joint (hand)
PIP stabilized while DIP flexed
PIP and DIP flexed
If flexion limited in both tests, capsule is tight
If flexing PIP increases DIP ROM, instrinsic muscles are tight
Special Tests (structure being tested & procedure): Froment's sign
Ulnar nerve dysfunction
Patients grasps paper between 1st and 2nd digits
Pull paper out
Look for IP flexion of thumb (compensation for weak AddPL)
May indicate ulnar nerve dysfunction
Special Tests (structure being tested & procedure): 2 point discrimintion test (hand)
Use paper clip/calipers etc to stimulate 2 points on palmar aspect of fingers
Record smallest distance patient is able to distinguish
Should be <6 mm
Special Tests (structure being tested & procedure): Allen test
Vascular compromise
Patient opens and closes their hand several times, then makes a fist
Oclude ulnar artery, then have patient open their hand
Observe palm, release and wait for filling
Repeat with radial artery
Special Tests (structure being tested & procedure): ULTT1
Median Nerve, anterior interosseous nerve, C5-7
Shoulder depression and 110 degrees abduction
Elbow extension
Forearm supination
Wrist extension
Finger/thumb extension
Contralateral neck side flexion
Special Tests (structure being tested & procedure): ULTT2
Median, musculocutaneous
Shoulder depression and 10 degrees abduction
Elbow extension
Forearm supination
Wrist extension
Finger/thumb extension
Shoulder ER
Contralateral neck side flexion
Special Tests (structure being tested & procedure): ULTT3
Radial
Shoulder depression and 10 degrees abduction
Elbow extension
Forearm pronation
Wrist flexion and ulnar deviation
Finger/thumb flexion
Shoulder IR
Contralateral neck side flexion
Special Tests (structure being tested & procedure): ULTT4
Ulnar nerve, C8-T1
Shoulder depression and 90 degrees abduction (hand to ear)
Elbow flexion
Forearm supination
Wrist extension and radial deviation
Finger/thumb extension
Shoulder ER
Contralateral neck side flexion
Special Tests (structure being tested & procedure): Patrick (FABER) test
Hip dysfunction (e.g. mobility restriction), iliopsoas dysfunction, SIJ dysfunction
Supine
Passive flexion, abduction, ER - foot resting just above opposite knee
Slowly lower testing leg to surface
(look for knee unable to assume relaxed position or for symptom reproduction)
Special Tests (structure being tested & procedure): Grind (Scouring) test
(aka quadrant)
Degenerative joint disease, AVN, osteochondral defect
Hip and knee flexion, hip adduction with pressure through joint
+ve = grinding, catching, crepitation
Special Tests (structure being tested & procedure): Ober's
ITB/TFL tightness
Side-lying, lower hip and knee flexed
Passively extend test hip with knee flexed to 90 degrees
Slowly lower to table (should come to rest on table)
Special Tests (structure being tested & procedure): Ely test
Rectus Femoris tightness
Prone
Flex testing knee
(look for ipsilateral hip flexion)
Special Tests (structure being tested & procedure): 90-90 hamstring test
Hamstring tightness
Supine, hip and knee supported in 90 degrees flexion
Passively extend knee as far as possible
(positive if unable to reach 10 degress from full extension)
Special Tests (structure being tested & procedure): Piriformis test
Supine, test foot placed on opposite knee
Testing hip adducted
(positive if testing knee unable to pass over resting knee or if symptoms reproduced)
Special Tests (structure being tested & procedure): Craig's test
Abnormal femoral anteversion angle
Prone, knee flexed to 90 degrees
Palpate greater trochanter, move hip through IR/ER
When greater trochanter feels most lateral, measure angle of leg relative to perpendicular
(norm= 8-15 degrees; <8 = retroverted; >15=anteverted)
Special Tests (structure being tested & procedure): Knee collateral ligament instability
Valgus/varus force in 20-30 degrees knee flexion
Special Tests (structure being tested & procedure): Lachman
ACL
Supine, knee flexed 20-30 degrees
Anterior draw
Special Tests (structure being tested & procedure): Pivot Shift
(Anterolateral rotary instability of the knee - ACL)
Supine, test knee extended, hip flexed and abducted 30 degrees, slight IR
PT grasps leg with one hand and places other over lateral surface of proximal tibia
IR, valgus force through knee with flexion
positive = palpable shift of clunk occurring between 30-40 degrees of flexion (ITB relocates tibia
Indicates anterolateral instability
Special Tests (structure being tested & procedure): Posterior sag
PCL
Supine, testing hip flexed to 45 degrees, knee flexed to 90
(look for tibia saggin posteriorly relative to femur)
Special Tests (structure being tested & procedure): Reverse Lachman
PCL
Prone, knee flexed to 30
Stabilize femur, glide tibia posteriorly
Special Tests (structure being tested & procedure): Apley
Differentiate between meniscal and ligamentous lesions
Prone, test knee flexed to 90 degrees
Stabilize thigh with knee
Passively distract knee joint, slowly rotates tibia internally and externally
(Pain or decreased motion during compression= meniscal)
Pain or decreased motion during distraction = ligamentous)
Special Tests (structure being tested & procedure): Hughston's plica test
Supine, test knee flexed, tibia internally rotated
Glide patella medially while palpating medial femoral condyle
Passively flex and extend knee
(look for pain and/or popping)
Special Tests (structure being tested & procedure): Clarke's sign
Patellofemoral dysfunction
Supine, knee extended, AP at patella superior pole
Patient contracts quads
(positive if painful)
Special Tests (structure being tested & procedure): Ballotable patella
(Patellar tap)
Infrapatellar effusion
Soft tap over central patella
(positive if patella "floats")
Special Tests (structure being tested & procedure): Fluctuation test
Knee joint effusion
Supine, knee extended
Push down over suprapatellar pouch
Push down over anterior aspect of knee joint
Alternate movements looking fluid movement
Special Tests (structure being tested & procedure): Q-angle
Angle between quads muscle and patellar tendon
(Norms: M=13 deg; F=18 deg)
Special Tests (structure being tested & procedure): Noble compression test
Distal ITB friction syndrome
Supine, hip flexed to 45 degrees, knee flexed to 90
Apply pressure to lateral femoral epicondyle, extend knee
(positive if pain reproduced over lateral epicondyle - should be at ~ 30 deg flexion)
Special Tests (structure being tested & procedure): Neutral subtalar positioning
Check for abnormal forefoot/rearfoot positioning
Prone, foot over edge of plinth
Palpate dorsal talus on both sides with one hand, lateral forefoot with other hand
DF until resistance is felt, move through supination/pronation
Neutral=point at which foot falls off easier to one side or the other
At neutral compare rearfoot to forefoot
Special Tests (structure being tested & procedure): Anterior drawer
Ligament instability (particularly ATFL)
Supine, heel off bed, 20 degrees PF
Stabilize lower leg, grasp foot
Pull talus anteriorly
(positive if excessive movement and/or pain)
Special Tests (structure being tested & procedure): Talar tilt
Ligament instability (especially calcaneofibular lig)
Sidelying, knee slightly flexed, neutral ankle
Adduct foot (CF lig)
Abduct foot (deltoid lig)
(positive if laxity or pain)
Special Tests (structure being tested & procedure): Thompson test
Achilles tendon integrity
Prone, foot off edge if plinth
Squeeze calf
(no movement = rupture)
Special Tests (structure being tested & procedure): Tinel's sign
Tap nerve to identify dysfunction:
- Posterior tibial nerve: posterior to medial maleolus
- Deep peroneal nerve: anterior to talocrural joint
- Median nerve: anterior wrist
- Ulnar nerve: cubital tunnel
(positive if pain/tingling/paresthesia produced in respective nerve distributions)
Special Tests (structure being tested & procedure): Morton's test
Identifies stress fractures and neuromas in forefoot
Supine
Grab around met heads and squeeze
(Positive if pain in forefoot)
Special Tests (structure being tested & procedure): VBI test
Assesses integrity of vertebrobasilar vascular system
Supine, head supported
Progress through following procedures if no symptoms produced after each step
1) Extend head and neck for 30 seconds
2) Extend head and neck with left then right rotation for 30 seconds
3) Cradle head off the table and extend head and neck for 30 seconds
4) Cradle head off the table and extend head and neck with rotation left then right for 30 seconds
(positive if dizziness, visual disturbances, disorientation, blurred speech, nausea or vomiting occur)
(MOBS/MANIPS AT CxSp WITHOUT TESTING VBI FIRST IS A BREACH OF CARE)
Special Tests (structure being tested & procedure): Hautant's test
Differentiates vascular versus vestibular causes of dizziness/vertigo
1) Patient sits with shoulders at 90 deg and palms up
Close eyes, sit still for 30 seconds.
(If arms loose their position there may be a vestibular condition)
2) Patient sits with shoulders at 90 deg and palms up
Close eyes, extend head and neck with rotation right then left remaining in each position for 30 seconds
(If arms loose their position there may be a vascular condition)
Special Tests (structure being tested & procedure): Transverse ligament stress test
Tests integrity of the transverse ligament
Supine
C1 PA (should be firm end-feel)
(Positive if end-feel is soft, dizziness, nystagmus, lump in throat, nausea etc.)
Special Tests (structure being tested & procedure): Anterior shear test
Assesses integrity of upper CxSp ligaments/capsules
Supine
PA C2-C7 (should be firm end-feel)
(Positive if end-feel is soft, dizziness, nystagmus, lump in throat, nausea etc.)
Special Tests (structure being tested & procedure): Foraminal compression (Spurling's test)
Dysfunction (usually compression) of CxSp nerve root
Sitting with head sidebent towards uninvolved side
Apply pressure straight down through the head
Repeat with sidebend the other way
(Positive if pain and/or paresthesia in dermatomal pattern for involved nerve root)
Special Tests (structure being tested & procedure): Maximum cervical compression test
Compression of neural structures at IV foramen and/or facet dysfunction
Sitting
Passively sidebend and rotate head towards non-painful side followed by extension
Repeat towards painful side
(BE CAREFUL-VERY SIMILAR TO VBI TEST)
(Positive if pain/paresthesia (nerve root) or localized neck pain (facet dysfunction)
Special Tests (structure being tested & procedure): Distraction test
Indicates compression of neural structures at IV foramen or facet dysfunction
Sitting, head passively distracted
(Positive if symptoms decrease (facet) or there is a decrease in upper limb pain (neurological)
Special Tests (structure being tested & procedure): Shoulder abduction test
Indicates compression of neural structures within IV foramen
Sitting, patient places one hand on their head, repeat with other hand
(positive if upper limb symptoms decrease)
Special Tests (structure being tested & procedure): Lhermitte's sign
Dysfunction of spinal cord and/or UMNL
Long sitting
Passively flex head and one hip while keeping knee extended
Repeat with other hip
(Positive if pain down the spine and into limbs)
Special Tests (structure being tested & procedure): Romburg's test
UMNL
Standing, close eyes for 30 seconds
(Positive if excessive swaying)
Special Tests (structure being tested & procedure): Rib Springing
Evaluates rib mobility
Prone
PA ribs beginning at upper ribs
Repeat in sidelying
(BE CAREFUL WITH RIBS 11 & 12 - NO ANT. ATTACHMENT = LESS STABLE)
(positive if motions is increased or restricted
Special Tests (structure being tested & procedure): Thoracic springing
IV joint mobility in thoracic spine
Prone
PA glides/springs to thoracic TPs
(Positive if pain, increased/decreased movement)
Special Tests (structure being tested & procedure): Slump test
Dysfunction of neurological structures supplying LL
Sitting on edge of plinth, knees flexed
Slump while maintaining neutral head and neck
Progress through following steps if no symptoms:
1) Passive head and neck flexion
2) Passive knee extension
3) Passive DF of extended leg
4) Repeat with other leg
(positive if near symptoms reproduced)
Special Tests (structure being tested & procedure): Lasegue's (SLR)
Dysfunction of neurological structures supplying LL
Supine
Passively flex hip with knee extended until shooting pain occurs
Slowly lowers until pain subsides, DF foot
(Positive if near symptoms reproduced when foot is DF)
Special Tests (structure being tested & procedure): Femoral nerve traction test
Compression of femoral nerve
Lie on non-painful side, trunk neutral, slight head flexion, lower-limb hip and knee flexed
Passively extend hip while knee of painful limb is in extension
If no symptoms, flex knee of painful leg
(Positive if neuro pain in anterior thigh)
Special Tests (structure being tested & procedure): Valsalva maneuver
Space occupying lesion
Sitting
Patient takes deep breath and holds it while "baring down" (as though having a bowel movement)
(Positive if LBP increases or near symptoms into LLs)
Special Tests (structure being tested & procedure): Babinski
UMNL
Supine or sitting
Glide bottom of reflex hammer along plantar surface of foot
(Positive if big toe extend and others abduct or "splay")
Special Tests (structure being tested & procedure): Quadrant
Compression of neural structures at IV foramen and facet dysfunction
Standing:
1) IV foramen: Side bend left, rotation left, extension. Repeat to right.
2) Facet: Side bend left, rotation right, extension.
Repeat to right.
(Positive if pain/paresthesia (IV foramen) or localized pain (facet).
Special Tests (structure being tested & procedure): Stork standing test
Spondylolisthesis
Stand on one leg
Extend trunk
Repeat with other leg
(Positive if pain in lower back with ipsilateral leg on the ground)
Special Tests (structure being tested & procedure): McKenzie side glide test
Differentiates between scoliotic curve and near dysfunction causing lateral shift
(Performed if lateral shift is noted)
Standing with PT on side of patient that spine is shifted towards
PT places their shoulders into patient's upper trunk and wraps arms around pelvis
Stabilize upper trunk, pull pelvis to bring into alignment
(Positive if neuro symptoms reproduced as alignment is corrected)
Special Tests (structure being tested & procedure): Bicycle (van Gelderen test)
Differentiates between intermittent claudication and spinal stenosis
Rides stationary bike with trunk erect
Time how long they can ride at set pace/speed
After sufficient rest ride again in slumped position
(If pain is related to stenosis patient should be able to ride longer while slumped)
Special Tests (structure being tested & procedure): Gillet's test
Assess movement of ilium relative to sacrum
Standing
PT thumb under PSIS of limb to be tested, other thumb on center of sacrum at same level as thumb under PSIS
Patient flexes hip and knee of test limb
Assess movement by comparing thumb position
(PSIS should move inferiorly)
(Positive if no movement of PSIS relative to sacrum)
Special Tests (structure being tested & procedure): Ipsilateral anterior rotation test
Assess anterior movement of ilium relative to sacrum
PT thumb under PSIS of limb to be tested, other thumb at center of sacrum at the same level and other thumb
Patient extends hip of test limb
Assess PSIS movement (PSIS should move superiorly)
(Positive if no movement as compared to sacrum)
Special Tests (structure being tested & procedure): Gaenslen's test
SIJ dysfunction
Sidelying at edge of table, holding bottom leg maximal hip and knee flexion
PT standing behind patient, passively extend hip of top limb (stresses ipsilateral SIJ)
(Positive if pain at SIJ)
Special Tests (structure being tested & procedure): Long sitting (supine to sit) test
SIJ dysfunction which may be the cause of leg length discrepancy
Supine in good alignment
PT at end of plinth, palpate medial maleoli, check symmetry
Patient moves to long sitting, reassess at maleoli
(Positive if limb lengths reverse from supine to long-sit)
Special Tests (structure being tested & procedure): Goldthwait's test
Differentiates between LxSp and SIJ dysfunction
Supine, PT fingers between SPs of LxSp
With other hand perform SLR
(If pain presents prior to palpation of movement at LxSp, dysfunction is related to SIJ)
Special Tests (structure being tested & procedure): TMJ compression
Compression of retrodiscal tissues
Sitting or supine
Stabilize head with one hand, with other push mandible superior causing compressing to TMJ
(Positive if pain reproduced)
Special Tests (structure being tested & procedure): Ludington's test
Assess for long head of biceps rupture
Sitting
Hands behind head, fingers interlocked
Pt alternately contracts and relaxes biceps muscles
Absense of movement = rupture
Special Tests (structure being tested & procedure): Allen test (thoracic outlet)
Sitting/standing
Test arm in 90 degrees abduction, ER, elbow flexion
Pt rotates head away from test shoulder while PT monitors radial pulse
+ve = diminshed/absent pulse
Special Tests (structure being tested & procedure): Mill's test
Lateral epicondylitis test
Pt sitting
PT palpates lateral epicondyle
Passive pronation, wrist flexion, elbow extension
Special Tests (structure being tested & procedure): Capillary refill test
Pt sitting/standing
PT compresses nailbed and after releasing the pressure notes the amount of time taken for the color to return to the nail.
+ve = delayed/muted response (greater than 2 seconds)
May indicate arterial insufficiency
Special Tests (structure being tested & procedure): Grind test (hand)
Pt sitting/standing
PT stabilize pt's hand, grasp thumb on metacarpal
Apply compression and rotation through met.
+ve = pain - indicates DJD at MCP joint
Special Tests (structure being tested & procedure): Piriformis test (from scorebuilder's)
Pt sidelying test leg up, hip flexed to 60 degrees
PT places one hand on pelvis, other on knee
While stabilizing pelvis, push (adduction force) down on knee
+ve = pain/tightness - may indicate piriformis tightness or sciatic nerve compression by piriformis
Special Tests (structure being tested & procedure): Tripod sign
Pt sitting with knees flexed to 90 degrees off edge of table
PT passively extends one knee
+ve = tightness in hamstring or trunk extension to limit efect of tight hamstring
Special Tests (structure being tested & procedure): Barlow's test
Test for hip dysplasia
Pt supine, hips flexed to 90, knees flexed
PT tests each hip individually by stabilizing femur and pelvis with one hand while other hand moves test leg into abduction while applying fwd pressure on greater trochanter
Click/clunk may indicate hip dislocation being reduced
Special Tests (structure being tested & procedure): Ortolani's test
Test for hip dysplasia
Pt supine, hips flexed to 90, knees flexed
PT grasps legs so thumbs are along pt's medial thighs and fingers are on lateral thighs towards buttocks.
PT abducts hips and gentle pressure is applied to greater trochs until resistance is felt at ~30 degrees.
+ve = click/clunk, may indicate reduction of a dislocation
Special Tests (structure being tested & procedure): Slocum's test
Pt supine, knee flexed to 90 degrees, hip flexed to 45
PT rotates pt's foot 30 IR (to test anterolateral instability)
PT rotates pt's foot 15 ER (to test anteromedial instability)
PT stabilizes lower leg by sitting on forefoot
Grasp prox tibia with two hands, thumbs on tibial plateau, PA to tibia on femur
+ve = movement of tibia occurring primarily on lateral side = may indicate anterolateral instability
Special Tests (structure being tested & procedure): Bounce home test
Pt supine
PT grasps heel, maximally flexes knee
Passively extend knee
+ve = Incomplete extension or rubbery end-feel
May indicate meniscal lesion
Special Tests (structure being tested & procedure): McMurray
Pt supine
PT grasps distal leg, palpates knee joint line
Medially rotate tibia and extend knee
Laterally rotate tibia and extend knee
+ve = click or pronounced crepitation felt over joint line
May indicate posterior meniscal lesion
Special Tests (structure being tested & procedure): Patellar apprehension sign
Pt supine, knees extended
Therapist places both thumbs on medial border of the patella and applies a laterally directed force
+ve = apprehension or quads contraction
May indicate patellar dislocation/subluxation
Special Tests (structure being tested & procedure): Tibial torsion test
Pt sitting with knees over table edge
PT places thumb and index finger of one hand over medial and lateral malleoli
PT measures acute angle formed by axes of knee and ankle
Normal lateral rotation = 12-18 degrees in an adult
Special Tests (structure being tested & procedure): Sitting flexion test
Pt sitting, knees flexed to 90, feet on floor
PT palpates PSIS' wtih thumbs
Monitor bony movements as pt bends forward to put hands on ground
+ve = one PSIS moving further in cranial direction and may indicate articular restriction